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By Chau Tran MD PGY-3​I knew the moment he arrived to Critical Care Bed 9 the patient was dead. His lifeless body stretched across the hard ER bed, chest compressions ongoing as the paramedic tried to do for the patient's heart what it could not do itself. His skin was cold and blue. His cardiac rhythm showed asystole. One look into his lifeless eyes and I knew, instinctively and viscerally, that this was not a patient that would be coming back. Once I had accepted this fact, a very real change occurred inside of me. When I accepted the inevitable reality of his death, the patient was no longer my main focus. Instead, his family became my top priority. They were not yet present in the ER, but were rapidly driving to the hospital. Unknowingly, they were coming to see him for what would be the very last time.

As an ER resident for the last 3 years at a large county hospital, I have been present for countless cardiac arrest resuscitations.More than I care to remember. More than I want to remember. At the critical point before ending the code, I looked to my attending for guidance. He turned to me, and with just a look, told me that I should do what I felt was right. Therefore, I continued our current endeavor because his family was not yet present. When his family arrived to the ER, I guided them over to their loved one’s room while full resuscitation was ongoing. After several more rounds of CPR, I called the code. The patient was pronounced dead. The monitors were turned off and the curtains were closed. The raw and grimy truth of human frailty and medical limits was laid bare for them to witness.

Allowing family members to be a part of medical resuscitation is a topic rife with controversy. While it felt natural and “right” to me in that moment, there is no consensus on the appropriateness of family presence during these crucial events. Medicine is built on facts and figures, hard truths that can be validated through clinical trials and published studies. How then, can we regulate something that is based on ethics and personal beliefs? This is the human side of medicine, the frustrating side that does not have a right answer. This is an aspect of medicine that makes itboth a science and an art form.Therefore, I did what I was accustomed to do when I didn’t know an answer: I “googled” it. Interestingly enough, there has been quite a bit of research attempting to answer this very question. An article by Halm aptly titled “Family Presence During Resuscitation” (Am J of Crit Care, 2005) reviewed 22 studies that were done from 1987 – 2005 on this topic. What she found was that most patients’ families want to be present during the resuscitation and felt that it helped with their grieving process. While there were conflicting results amongst the studies, it seemed that the majority of physicians and nurses also favor having family present. Unfortunately, the overwhelming majority of hospitals do not have any policies in place to guide this practice. Therefore, medical providers must independently coordinate between the ED team and the family to incorporate this into the resuscitation. A more recent article from Yale-New Haven Hospital (Yale J of Bio and Med, 2014) conducted a study among its own medical staff to determine their preference.

They found that 77% of their staff strongly favored allowing the option for family presence. Based on this result, the authors concluded that a protocol should be written specifically for the ED to serve this very purpose. Multiple studies have also been done amongst the pediatric patient population. The results from these studies showed that there were beneficial effects to grieving families in being present for resuscitations. Therefore, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) issued a joint statement in 2006 recommending that the option of family member presence should be encouraged for all aspects of ED care.

What then about lawsuits and litigation that comes with this practice? Opponents of family presence fear the disruption that comes with extra bodies in tight quarters. They also fear the unrealistic expectations of family members looking for a miracle. A New England Journal of Medicine (NEJM) article published in 2013 seemed to address some of these concerns. In this prospective study done in France, EMS units were divided in two groups: one that gave family members the option to witness CPR (intervention) while the other did not routinely offer it (control). While both groups had a significant number of family presence (79% vs. 43%, intervention vs. control), their primary end point, PTSD-related symptoms at 90 days, was significantly higher in the control group than the intervention group. They also found no difference in medicolegal claims, resuscitation effort, or survival rate between the two groups despite the percentage difference in family presence. Are the fears of litigation unfounded then? Perhaps. Then again, can we translate the result of a French study to our own litigious American legal environment?

There are several ethics articles written on this topic as well. Unfortunately, even ethicists do not have the answer. An editorial article written by Haddad (RN, 2002) discussed the opposing side of this argument. The only recommendation I could glean was to tread lightly, and to assess the family for their own preparedness for what will be seen. The right answer, according to this author, is patient and family-centric. While providing that opportunity is important, not every family is ready or willing. Some family members may choose not to be present; in those cases, we should be respectful of those wishes no matter what our beliefs.

Once again, there is no straightforward answer to the question of family presence during resuscitation. For me, though,the answer was clear. It was not based on hard science, but on what I feltwas the right thing to do based on my moral compass. In the final moments of my patient’s life, I dedicated that time to his family. The art of medicine is in knowing one’s limitations and still, despite this, providing care. I could not bring him back from the dead. I could not change the inevitable course of him dying. However, I can still care for his family by providing them closure and comforting them in their darkest time. And in doing so, I left my shift that night satisfied, knowing that I too, received my closure.

There are several ethics articles written on this topic as well. Unfortunately, even ethicists do not have the answer.

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